David Berkowitz

ACCURATE CHARACTERIZATION OF EXTRAVASCULAR LUNG WATER IN ACUTE RESPIRATORY DISTRESS SYNDROME

Objectives:Measurements of extravascular lung water (EVLW) correlate to the degree of pulmonary edema and have substantial prognostic information in critically ill patients. Prior studies using single indicator thermodilution have reported that 21% to 35% of patients with clinical acute respiratory distress syndrome (ARDS) have normal EVLW (<10 mL/kg). Given that lung size is independent of actual body weight, we sought to determine whether indexing EVLW to predicted or adjusted body weight affects the frequency of increased EVLW in patients with ARDS. Design:Prospective, observational cohort study. Setting:Medical and surgical intensive care units at two academic hospitals. Patients:Thirty patients within 72 hrs of meeting American-European Consensus Conference definition of ARDS and 14 severe sepsis patients without ARDS. Interventions:None. Measurement and Main Results:EVLW was measured for 7 days by PiCCO transpulmonary thermodilution; 225 measurements of EVLW indexed to actual body weight (ActBW) were compared with EVLW indexed to predicted body weight (PBW) and adjusted body weight (AdjBW). Mean EVLW indexed to ActBW was 12.7 mg/kg for ARDS patients and 7.8 mg/kg for non-ARDS sepsis patients (p < .0001). In all patients, EVLW increased an average of 1.1 ± 2.1 mL/kg when indexed to AdjBW and 2.0 ± 4.1 mL/kg when indexed to PBW. Indexing EVLW to PBW or AdjBW increased the proportion of ARDS patients with elevated EVLW (each p < .05) without increasing the frequency of elevated EVLW in non-ARDS patients. EVLW indexed to PBW had a stronger correlation to Lung Injury Score (r2 = .39 vs. r2 = .17) and Pao2/Fio2 ratio (r2 = .25 vs. r2 = .10) than did EVLW indexed to ActBW. Conclusions:Indexing EVLW to PBW or AdjBW reduces the number of ARDS patients with normal EVLW and correlates better to Lung Injury Score and oxygenation than using ActBW. Studies are needed to confirm the presumed superiority of this method for diagnosing ARDS and to determine the clinical treatment implications.

A randomised trial of lung sealant versus medical therapy for advanced emphysema

Uncontrolled pilot studies demonstrated promising results of endoscopic lung volume reduction using emphysematous lung sealant (ELS) in patients with advanced, upper lobe predominant emphysema. We aimed to evaluate the safety and efficacy of ELS in a randomised controlled setting. Patients were randomised to ELS plus medical treatment or medical treatment alone. Despite early termination for business reasons and inability to assess the primary 12-month end-point, 95 out of 300 patients were successfully randomised, providing sufficient data for 3- and 6-month analysis. 57 patients (34 treatment and 23 control) had efficacy results at 3 months; 34 (21 treatment and 13 control) at 6 months. In the treatment group, 3-month lung function, dyspnoea, and quality of life improved significantly from baseline when compared to control. Improvements persisted at 6 months with >50% of treated patients experiencing clinically important improvements, including some whose lung function improved by >100%. 44% of treated patients experienced adverse events requiring hospitalisation (2.5-fold more than control, p=0.01), with two deaths in the treated cohort. Treatment responders tended to be those experiencing respiratory adverse events. Despite early termination, results show that minimally invasive ELS may be efficacious, yet significant risks (probably inflammatory) limit its current utility. Emphysematous lung sealant therapy is highly efficacious in some patients, but benefits bring significant risks http://ow.ly/JJ2vg

Pleuroscopy for Diagnosis and Therapy for Pleural Effusions

Pleuroscopy, also known as medical thoracoscopy, is a minimally invasive procedure to inspect and perform a biopsy of the pleural space as well as to perform therapeutic interventions. It differs from conventional video-assisted thoracic surgery in that it may be performed under moderate sedation in the endoscopy suite without the need for intubation or single-lung ventilation. The diagnostic accuracy of this procedure approaches 100% in malignant and tuberculous pleural effusions. Complication rates are low (2%-5%) and are typically minor (subcutaneous emphysema, bleeding, infection), with mortality rates <0.1%. Therapeutic interventions, such as chemical pleurodesis, may be performed during pleuroscopy for recurrent, symptomatic malignant pleural effusions, with success rates approaching 90%. In trained hands, pleuroscopy is a safe and well-tolerated procedure with high diagnostic accuracy and therapeutic efficacy.

Multicenter experience with electromagnetic navigation bronchoscopy for the diagnosis of pulmonary nodules.

Background:Physicians are increasingly encountering lung nodules in their practice, and tissue diagnosis is often required. Conventional bronchoscopic sampling yields a range from 14% to 69% depending on the nodule size and location within the lung. We aimed to evaluate the diagnostic yield of electromagnetic navigation bronchoscopy (ENB) in multiple centers and to determine what factors affect the yield of ENB. Methods:A retrospective analysis of 92 consecutive ENB procedures at 5 centers was carried out. Data were collected on patient demographics, nodule characteristics, complications, type of samples obtained, diagnosis, and follow-up studies. Variables were analyzed to determine as to which factors had an impact on the diagnostic yield with multiple logistic regression analysis. Results:Ninety-two patients underwent EMB at 5 centers between December 2008 and October 2009. The average nodule size was 2.61 cm (SD 1.42) at a distance of 1.81 cm (SD 1.32) from the pleural surface. The overall yield for ENB-guided sampling of pulmonary nodules was 65% (60/92). The ENB yield for nodules ⩽2 versus >2 cm in size was significantly less after controlling for the distance from the pleura (50% vs. 76%, respectively; P=0.01). The distance from the pleura did not affect the ENB diagnostic yield after controlling for nodule size (P=0.92). The lobar location of the nodule also did not affect the diagnostic yield (P=0.59). Conclusions:The diagnostic yield of ENB-guided sampling of pulmonary nodules is impacted by the nodule size, but not by the distance from the pleura or the lobar location.

Outcomes, Health-Care Resources Use, and Costs of Endoscopic Removal of Metallic Airway Stents

BACKGROUND The use of self-expandable metallic airway stents (SEMAS) for airway compromise may be associated with significant complications requiring their removal/replacement. The aim of this study is to describe the complications, health-care resources use (HRU), and costs associated with endoscopic removal of SEMAS. METHODS A retrospective analysis of patients who underwent endoscopic removal of SEMAS during a 10-year period (January 2000-August 2009) was performed. HRU was analyzed in terms of the number of endoscopic procedures, hospital and ICU stay, need for mechanical ventilation and airway restenting, and estimation of respective hospital costs. RESULTS Fifty-five SEMAS were removed from 46 patients with a mean age of 58.6 +/- 15.8 years. Eighty percent of the stents were placed for benign airway disorders with an average stent in situ duration of 292 days. The median number of removal and total procedures during each encounter was one and two, respectively. Patients required hospitalization and ICU admission in 78% and 39% of the encounters with a median length of stay of 3.5 and 0 days, respectively. The estimated median total cost per encounter to remove the stents was

Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee

10,700, ranging from

Alcohol abuse enhances pulmonary edema in acute respiratory distress syndrome.

3,700 to

Validation of an Interventional Pulmonary Examination

69,800. The measured outcomes were statistically significantly better when in situ stent duration was <or= 30 days (P < .05). CONCLUSIONS Endoscopic removal of SEMAS is feasible; however, it is associated with significant complications, HRU, and costs. The use of SEMAS should be restricted to a well-selected patient population and should be planned by a team experienced with this type of therapeutic strategy.

Effect of routine clopidogrel use on bleeding complications after ultrasound-guided thoracentesis.

&NA; Interventional pulmonology (IP) is a rapidly evolving subspecialty of pulmonary medicine. In the last 10 years, formal IP fellowships have increased substantially in number from five to now > 30. The vast majority of IP fellowship trainees are selected through the National Resident Matching Program, and validated in‐service and certification examinations for IP exist. Practice standards and training guidelines for IP fellowship programs have been published; however, considerable variability in the environment, curriculum, and experience offered by the various fellowship programs remains, and there is currently no formal accreditation process in place to standardize IP fellowship training. Recognizing the need for more uniform training across the various fellowship programs, a multisociety accreditation committee was formed with the intent to establish common accreditation standards for all IP fellowship programs in the United States. This article provides a summary of those standards and can serve as an accreditation template for training programs and their offices of graduate medical education as they move through the accreditation process.

Transbronchial Lung Cryobiopsy and Video-assisted Thoracoscopic Lung Biopsy in the Diagnosis of Diffuse Parenchymal Lung Disease. A Meta-analysis of Diagnostic Test Accuracy

BACKGROUND Pulmonary edema is a cardinal feature of the life-threatening condition known as acute respiratory distress syndrome (ARDS). Patients with chronic alcohol abuse are known to be at increased risk of developing and dying from ARDS. Based upon preclinical data, we hypothesized that a history of chronic alcohol abuse in ARDS patients is associated with greater quantities and slower resolution of pulmonary edema compared with ARDS patients without a history of alcohol abuse. METHODS A PiCCO transpulmonary thermodilution catheter was inserted into 35 patients within 72 hours of meeting American European Consensus Criteria definition of ARDS. Pulmonary edema was quantified as extravascular lung water (EVLW) and measured for up to 7 days in 13 patients with a history of chronic alcohol abuse and 22 patients without a history of chronic alcohol abuse. RESULTS Mean EVLW was higher in patients with a history of chronic alcohol abuse (16.6 vs. 10.5 ml/kg, p < 0.0001). Patients with alcohol abuse had significantly greater EVLW over the duration of the study (RM-ANOVA p = 0.003). There was a trend towards slower resolution of EVLW in patients with a history of alcohol abuse (a decrease of 0.5 ml/kg vs. 2.4 ml/kg, p = 0.17) over the study period. A history of alcohol abuse conferred a greater than 3-fold increased risk of elevated EVLW [OR 3.16, (1.26 to 7.93)] using multivariate logistic regression analysis. CONCLUSIONS In patients who develop ARDS, alcohol abuse is associated with greater levels EVLW and a trend towards slower resolution of EVLW. Combined with mechanistic and preclinical evidence linking chronic alcohol consumption and ARDS, targeted therapies should be developed for these patients.